Journal of Adolescence 1992, 15,449-466

Sex education: more is not enough ALEX MELLANBY,

FRAN PHELPS

AND JOHN TRIPP

Increasing demands for sex education have been associated with a plethora of recommendations, regulations and resources with resulting variability of content, strategy, quality and outcome. While numerous studies confirm that the health behaviour of teenagers is not altered by the teaching of facts alone, other data suggest that appreciation of personal risk and learned assertiveness skills are associated with changes in population behaviours. Peer led teaching is a powerful and probably essential component of school health and sex education. Evaluated interventions with agreed purpose and acceptable methodologies are essential if there is to be any real expectation of health benefit from sex education.

INTRODUCTION Teachers

of sex

education,

a minority

non-examination

school

subject

busy curriculum, are being asked to prevent teenage pregnancies, reduce the risk of AIDS, provide the Nation with a happier healthier lifestyle, and much more. Calls for more sex education are not new; in many countries, they have become more strident as related teenage medical problems have increased. The numbers of pregnancies and abortions are rising (Royal College of Obstetricians and Gynaecologists (RCOG), 1991), more teenagers are contracting sexually transmitted diseases with associated complications (Donovan, 1990), and cervical abnormalities, probably causally associated with sexually transmitted viral infections, are being detected at an earlier age (Elliott, 1989). While financial support, government policy, litigation and pressure groups influence sex education and family planning (Muraskin, 1986; Kenney, 1989; Vincent, 1990; Gold, 1991; Anonymous, 1991), it is HIV/AIDS that has provided the recent major driving force to increase sex education, and one that has caused young teenagers to be showered with more sexual information than ever before (Times Educational Supplement (TES), 1992). squeezed

in an

already

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Association

Department

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of Child Health,

in Services

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Kirby suggests that “sex education today reflects the values and beliefs about sexuality in our culture” (Kirby, 1984). Government, parents, teachers, governors and others acknowledge the need for the inclusion of sex education in schools which is now provided for most children (Allen, 1987). In the last thirty years, sex education in schools has been changed largely as a result of external pressures; these changes should be viewed in the context of development in curriculum theory and practice. Health educators argue over the most appropriate and effective approaches to health and sex education (Clift, 1989). These views reflect the proponents of educational thinking, from the “traditional” through the “progressive” to the “radical”; the questions are: what is the function of a teacher and what are the appropriate strategies for students’ learning? The answers tend to polarise teachers and health professionals both as practitioners and theorists (Darling, 1978). The British Government’s HIV/AIDS campaign stimulated many local authorities to provide in-service training for teachers. This caused a dilemma for some school governing bodies: those who had decided against the provision of sex education and those Catholic schools which have specific views on contraception. This campaign has promoted safe sex with the possible criticism that this assumes sexual activity. It is unclear whether those promoting the dissemination of knowledge about contraception and condoms would consider an increase in teenage sexual activity to be a serious unwanted side effect. It has also been suggested that some schools might include AIDS education within health rather than sex education (Mahoney, 1988) but this arbitrary separation of AIDS from sex is viewed by others as a “nonsense” (Rivalland, 1988). The current situation in British schools is complex. The Education Reform Act (1988) requires the governors of a school to have oversight of the content of the sex education curriculum, to consider how parents and outside speakers should be used (Department of Education and Science (DES), 1987) and that the curriculum should, “promote the spiritual, moral, cultural, mental and physical development of the pupils at the school and . . . prepare pupils for . .. adult life” (National Curriculum Council (NCC), 1989). Guidelines for schools are now provided by the NCC (1990) and some Local Educational Authorities (Thomson, 1992). Students should study the physical and emotional changes of puberty, the ways in which the healthy functioning of the human body may be affected by bacteria and viruses including HIV and to understand the need for a responsible attitude to sexual behaviour (DES, 1991). Parents, through the school governing body, have been given more responsibility for sex education. Attitudes to this new responsibility vary but are welcomed by many parents, the majority of whom want schools to

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play a major part in the sex education of their children (Jackson, 1982; Went, 1985; Allen, 1987); many of these parents are ignorant of the content and context of their children’s lessons (Went, 1985). Some schools are reluctant to involve parents in curriculum development (Phelps, 1991); there are concerns that articulate governors may successfully promulgate views which neither represent those held by most parents nor teachers (Golby and Brigley, 1989). However, this increase in responsibility does not necessarily mean taking the responsibility away from teachers; the involvement of parents and other interested groups should contribute to improved curriculum development and the provision of effective support for the school and its policies. Whilst some parents pay particular attention to school policy and practice, schools are often disappointed by lack of parental attendance at information evenings (Phelps, 1991). Students’ views are infrequently taken into account; however, in Allen’s study, about three quarters of the students considered that the quantity of sex education was about right; about a fifth commented that there was too little provision, with about 32% specifying particularly personal relationships, contraception or venereal disease (Allen, 1987). Policy may not always be translated into practice; The Education Act (No.~), required Local Education Authorities or governors to inform parents of the manner and context in which education about sexual matters was to be given (1986). A recent report expresses concern that “so many schools have not developed policies at all and others have not articulated good practice into policies” (Thomson, 1992). Teachers have been expected to manage changes in sex education and to cope with sensitive issues without sufficient training, support or critical appraisal, and are often selected for expediency rather than expertise programmes, incorpo(Went, 1985; Phelps, 1991). Various “Lifeskills” rating active learning, were developed after the findings of associations between low self-esteem and unsafe teenage behaviour (Reid, 1983). Many teachers found these programmes too demanding, some were required to change their teaching styles, others were concerned about the political and social issues behind these curriculum decisions (Skilbeck, 1976). imposition of innovative methodologies which threaten existing practice and require new structure (usually “top down”) are less likely to succeed. Innovation which increases status by extending teacher responsibility, enhancing teacher initiated change, and increasing teacher autonomy is more likely to be successful (Holt, 1978). Curriculum development draws on all of a teacher’s competence and skills; it is intellectually demanding and its success depends upon the development of quite substantial support systems (Skilbeck, 1975). Whilst many programmes have been successfully institutionalised and teachers have incorporated these

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styles into their teaching method, others, with inadequate support, have resisted the pressure to change (Phelps, 1991) or have reverted to curriculum and teaching styles with which they feel more confident and competent (Skilbeck, 1975). A cross curricular approach aims to counter the complexities of the sex education curriculum (Hovey, 1988) but inherent problems with co-ordination (Pring, 1984) and with teachers, who consider themselves ill-prepared and unsupported, remain. If one of the most important issues to be addressed in the provision of sex education is teachers’ feelings of uncertainty and embarrassment (Thomson, 1992), then these teachers need the confidence and support of parents, governors and the community. The “medical model”, described as emphasising the use of biological knowledge, statistics and epidemiology (Seedhouse, 1986), has been identified as being the basis for Personal, Social and Health Education programmes and is probably the most widely used approach for teaching HIV/AIDS (Clift, 1989) and sex education. This model has been criticised as having the assumptions that: “medical and health experts have the knowledge which enables them to know what is in the best interest of their patients and the public at large” (Ewles and Simnett 1985) which is clearly untenable. Accepting that sex education was more than the prevention of teenage pregnancy or sexually transmitted disease, many schools extended the content of their programmes and incorporated relationships and parenthood (Reid, 1982); many teachers found it easier to teach about parenthood and spent less time on relationships (Curtis, 1989). Sex education had moved into other areas of the curriculum; “Option Packages” resulted in some students in the 14-16 age group repeating similar content in different subjects whilst others received none (Reid, 1982). On the assumption that health is a “positive goal, and something which can be achieved personally” (Seedhouse, 1986), an alternative model for health promotion attempts to promote freedom of choice and informed decision-making. As real choice is limited, promotion of self empowerment is seen as more likely to enable a person to make their own decisions about their health possibly achieving “preventive outcomes” and the adoption of “prudent lifestyles” (Tones, 1987). These models for health education reflect the curricula offered by the two extremes of the teaching; there is popular backing for teachers to ensure that children obtain the maximum number of academic qualifications but teaching also has a “social control, social welfare side; . . . it is often uncivilised, a struggle to maintain order in a confined space, outnumbered 30 to one by experienced disrupters” (Shipman, 1984). The public is often unaware of the time expended by teachers on students’ non-academic difficulties. Some would argue that this is not an ‘educa-

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tional” requirement but to teach successfully, students need to be able to learn successfully (Pring, 1984). Personal education programmes were introduced in an attempt to provide student guidance. Staff appointments were made to co-ordinate these programmes and to raise their status in the academic/personal curriculum divide. These courses may have often euphemistically called Personal included sex education, Relationships; ironically, a Health Education course may not include any aspect of sex education (Watson, 1983). Whilst videos and drama productions may have the advantage of not requiring trained personnel to teach specific and sensitive issues, they may limit the use of other strategies (Biglan, 1988). Peer education is seen by some as the answer to this dichotomy (Russell, 1992). Many teachers are concerned with imposing values on students, others accept that teaching cannot be value free; selection of curriculum content and resources reflect values and are in themselves value statements (Jackson, 1982). Each approach will have its merits, teachers are perhaps more adept than theorists in recognising when one method is more appropriate than another (Darling, 1978) and experienced teachers are able to vary their approach. However, individuals or groups of teachers would have difficulties in implementing “radical” programmes into an essentially “traditional” establishment. Given the difficulties of imparting facts, it must be welcomed that the emphasis of sex education has moved to include responsibilities and decisions within relationships (DES, 1986). Sex education programmes have been devised which allow for more informal discussions about relationships and the problems faced by teenagers. Unfortunately we cannot be confident that these approaches will have any greater health impact. Several well constructed sex education initiatives based on these wider considerations have failed to achieve success (Kirby, 1984). In particular they have been unable to reduce the problem of teenage pregnancy. What sex education a student receives is determined by educational models, plus media, medical, governmental, governors, schools’ and individual teacher’s aims and objectives, with the additional rider that the student’s presence is also required. The diversity of sex education, and the complexity of some questions asked (Kirby, 1989), may invalidate extrapolation from sample studies to the whole teenage population. However, the information gathered has shown that teenagers lack understanding about basic anatomy and physiology (Phelps, 1992). Half of 12-13 year old American teenagers in one study thought that a girl could not get pregnant at first intercourse (Parcel, 1981). We found that one fifth of 15-16 year old teenagers considered mid-cycle to be the “safest” time to have intercourse without causing a pregnancy (Mellanby, 1991). Teenagers may be aware of the names of contraceptive methods (Black,

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1979) but in our study of 15-16 year olds 33% believed that condoms were 100% effective in preventing pregnancy (Mellanby, 1992) and 73% believed that a girl could not get pregnant if she was taking the pill regularly (Mellanby, 1991). They appear to know of the risks and methods of transmission of HIV (Ford, 1989), but have little knowledge and even less understanding of other sexually transmitted diseases. One third of teenagers in our study considered condoms to be 100% effective contraception, but two thirds thought condoms were totally protective against all sexually transmitted disease (Mellanby, 1992). Teenagers with inadequate knowledge, relying on myths and inaccuracies, are less able to appreciate risks. Sex education can improve knowledge (Monge, 1977; Parcel, 1979 and 1981; Zelnik, 1979; Block, 1980; Kilman 1981; Kirby, 1984; Cull-Wilby 1985; Benson, 1986; Herz, 1986). Correcting misconceptions is important but providing factual information alone does not change teenage behaviour (Botvin, 1989). Why individuals do or do not make decisions, informed or otherwise, is a major concern of health educators. Whatever models are used to explain health related behaviour several authors conclude that young teenagers have not reached a stage of cognitive development allowing them to make decisions about health risk based on facts (Cobliner, 1974; Blum, 1982; Sachs, 1986; Gruber, 1987). Teenage sexual activity may involve one person who incorrectly assumes they are making autonomous decisions and another who is uncertain but less powerful; this is not necessarily gender specific. In this type of relationship negotiations surround physical progression not protection; such discussion might weaken the argument to progress (Kisker, 1985). As Spanier (1975) suggests, “individuals may change their sexual behavior (and their values and standards as well) in a brief period of time if the opportunity exists and the circumstances surrounding a given situation encourage it”. This may explain why surveys show that teenagers are concerned about the risks of sexually transmitted disease but show little alteration in behaviour (Ford, 1989), and why some sex education can alter “pen and paper” attitudes, but not reduce risk taking (Kirby, 1984). Attitudes are easier and faster to assess than actions, but given their predictive limitations sex education programmes should not rely on attitude evaluation alone. Behavioural evaluation suggests that when young teenagers are able to make autonomous decisions they will in fact tend to postpone sexual involvement (Howard, 1990). As well as reducing their risks of pregnancy and sexually transmitted disease, this allows teenagers to make decisions which they will not regret at a later date (Curtis, 1988). Behaviour is, at least partially, determined by the attitudes held within society (Baric, 1977; Bandura, 1977). Media images and impressions are powerful determinants of the “naughty but nice” attitude toward teenage

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sexuality. The extensive television portrayal of sexual activity may directly influence teenagers’ behaviour (Brown, 1991). Television more often illustrates sex as a process for younger rather than older individuals, and unmarried rather than married couples (Brown, 1991). A skewed view of normality and an over-estimation of teenage sexual activity is a feature of media reporting; headlines proclaim that most teenagers are having sex before 16, when the survey reports they describe do not bear out these facts (Hall, 1992). Concepts of what is considered normal are important determinants of behaviour and the provision of “normative” data is an important tool in health promotion (Baric, 1977). Incorrect statistics about teenagers may leave those under 16 who are not sexually active considering that they are “abnormal”. It is probably impossible to alter media strategies but it is possible to expose these strategies within a sex education programme. Families are important and the role of parents in the provision of sex education needs careful consideration. Some parents will have specific ideas about conducting sex education whilst others may be content to devolve the process to others (Allen, 1987). Teenagers are often unaware of parental views about sexual activity (Newcomer, 1985) and as Bell (1966) says: “For many parents and their children, the conflict about premarital sex will continue to be characterised by the parent’s playing ostrich and burying his head in the sand, and the youth’s efforts to keep the sand from blowing away.” Many parents having not had any sex education themselves may need more information before they can increase their involvement in sex education. Educational programmes involving parents can increase teenage (and parental) knowledge, improve family communications and in some cases improve teenage contraceptive use (Inazu, 1980) but not assist teenagers to resist pressure in relationships (Casper, 1990). What impact can we predict that current sex education will have? Despite calls for research into the behavioural effects of health education in Britain, there have been few attempts to determine outcomes other than to measure a programmes acceptability (Wayne, 1992), reflecting the philosophical disagreement on aims of this type of education. Healthier decisions may be a desired aim of sex education, but some consider it will only increase sexual activity (Pawsey, 1980). Several large surveys refute this (Zelnik, 1982, Furstenberg, 1985; Dawson, 1986; Cullari, 1990). The work of Marsiglio and Mott (1986) IS . cited as conflicting evidence. Their study concluded that females, but not males, who had sex education prior to their 15th or 16th birthdays were more likely to initiate intercourse at these ages. Although this factor was the weakest measured variable associated with coital initiation, it demonstrates the necessity for evaluation of

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sex education. Sex education has, at least in the past, focused on the supply of factual information (Reid, 1983). Other health education programmes suggest that this is probably ineffective, and possibly harmful. Providing information about the adverse effects of alcohol can increase alcohol consumption by teenagers (Rundall, 1988). Effective health education about drugs, including alcohol and tobacco, may need to contain few or no facts (Glynn, 1989). Sex education courses providing mostly factual information have generally not succeeded in reducing problems associated with teenage sex. They have not altered teenagers’ decisions about initiation of coitus nor reduced teenage pregnancies (Kirby, 1984; Dawson, 1986; Herz, 1986). Certain programmes have shown an increase in contraceptive usage (Schinke, 1981; Dawson, 1986). Increased contraceptive use does not equate with effective use and young teenagers, informed about contraception and HIV/AIDS, have neither used contraception consistently nor reduced their sexual risk taking (Dawson, 1986; Ford, 1990). Sexual activity is a complex area and a generalised appreciation of the risks, such as might be expected with drugs, may be absent. While didactic or formal education about health may have little impact on behaviour, a lack of knowledge is a risk factor for teenage pregnancy (Ashken, 1980). Evaluated sex education courses may be criticised as sociological experiments and not reflecting long term classroom practicalities. This does not, however, preclude our learning from such courses and concluding that further work is required in defining even the factual content and its transmission in sex education courses. Stout (1989) in his review of five major pieces of research concluded “The available evidence indicates that there is little or no effect from school based sex education on sexual activity, contraception, or teenage pregnancy”. It would appear that we cannot rely on informed teenagers being able to select healthier lifestyles. In response to rising American teenage pregnancy rates other methods such as school based health clinics have been tried. These clinics were originally established in response to the high level of medical problems found in some inner city schools (Dryfoos, 1985). Several clinics started to provide sex education courses and contraceptive services and in 1988 there were 138 clinics of which 21% dispensed contraception (Dryfoos, 1988) although only lo-15% of consultations were for contraceptive services. Initial results indicated that such clinics could decrease teenage pregnancy rates (Edwards, 1980) This reduction was not associated with an increase in sexual activity and may have been associated with some delay in the initiation of sexual intercourse (Dryfoos, 1988). The current provisions of primary care in Britain would prevent the establishment of such clinics, and it is unlikely for them to receive much approval from anyone other than the teenagers!

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However, these clinics demonstrate that providing easily available contraception to teenagers, rather than the information alone, may increase their effective use. Other innovative intervention programmes have derived from psychological theories such as Social Learning Theory (Bandura, 1977). The application of such theories can probably be traced to earlier behavioural techniques used with individuals such as long stay psychiatric patients or juvenile delinquents (Braukmann, 1975). The aim is to create an environment where altered behaviour is encouraged by stimulating individual changes in attitude, and probably most important, enabling practical experience of different behaviours (Clark, 1974). Using these techniques a number of adolescent programmes have derived from what can be broadly termed, learning assertiveness and refusal skills. In these studies teenagers are confronted with pressure to engage in risk behaviours and given the opportunity to practise saying “No”. Such programmes have had considerable effect on smoking onset and drug taking (Botvin, 1989). Sex education programmes relying on teaching refusal skills alone have not achieved their aims (Christopher, 1991). Those which have, possibly, selected a more balanced approach have achieved more. Howard (1990), working from a clinic to provide medical and family planning services to teenagers, achieved considerable reductions in teenage pregnancy and improved contraceptive use. The teenagers in her study were 5 times less likely to have become sexually involved at age 16 than those who had not had the programme, although it should be noted that the results from this study derive from a small sample of the population involved. Vincent (1987), using a widespread community and school education programme (including local radio, leaflets etc) coupled with learned techniques to counteract pressure, achieved a greater than 50% reduction in teenage pregnancy. These two programmes used peer educators (“peer” being taken to include individuals two to three years older) to discuss teenage relationships in addition to more formal provision of factual information. Using older students in education is not a novel concept (Davis, 1977; Wagner, 1982); they are seen as role models and more acceptable sources of information about risky behaviour than adults (Perry, 1989). They appear to have more success than adults in assisting younger teenagers to make autonomous decisions and develop skills to deal with unwelcome sexual pressures. Counteraction of other external pressures, such as the media, are harder to achieve. Vincent’s study (1987) addressed some of the problems by a sustained dissemination of information about teenage sexuality through local media outlets. Other projects have used drama productions (Hillman, 1991) and the commissioning of rock songs (Silayan-Go, 1990),

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both with some success. However, these would be impossible to sustain over a long period, and would not counteract the television and film viewing of teenagers. Possibly of more fundamental importance than achieving objectives in sex education is reaching an agreement on what the objectives should be. Only then will effective methodologies actually be delivered in the classroom. Objectives might include improving the quality of individuals’ sex lives, increasing their knowledge of sexuality and reproduction, decreasing the problems associated with teenage sexual activity or, possibly, all of these. Others may have very different ideas about the aims of sex education, including the positive discrimination for those who have minority life-styles. The government in the U.K. acknowledged that “factual information about the physical aspects of sex” is important but not more important than “the qualities of relationships in family life and of values, standards and the exercise of personal responsibility as they affect the individual and the community at large” (DES, 1986). More recently a British Government White Paper called for aims in sexual health (Health of the Nation, 1992) targeting reduction of under 16’s pregnancies and reduction in STDs by “education and the continued development of local services”. This was preceded by the Report from the RCOG on unplanned pregnancies, which concluded that it would be desirable to reduce the adverse effects (of unwanted teenage pregnancies, and abortions), specified detailed proposals for sex education and, concerning teenage sexual activity, that “Strategies must be developed to minimize the harm and maximize the benefit” (RCOG, 1991). Other interested bodies have pronounced on sex education: the Family Planning Association called for a Sex Education Charter to improve “reproductive health” (1991); the Catholic Church considers that it is a primary duty of parents and auxiliary but essential duty of school (Vatican Congregation 1983); the General Synod of the Church of England writes that “a right understanding and attitude to sex can lead to a positive sense of personal identity and value” (1988). The Sex Education Forum (1992) (incorporating the views of these last three bodies and others) proposes that it should “foster self esteem, self awareness, a sense of moral responsibility and the skills to avoid and resist unwanted sexual experience”. The media has with calls for more sex education maintained extensive coverage (Strickland, 1991), as well as less (Kenny, 1991). In general, the medical profession has allied itself with those wishing to increase sex education (Donovan, 1990; RCOG, 1991). Some educationalists have expressed considerable concerns about the aims and objectives of sex education, and if it is in fact “education” at all or indoctrination (Quicke, 1985). However, a British Secretary of State for Health declared “It is wrong to

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let a personal claim to the right to be free embrace ill-health, incapacity, disease and death, to become a dictatorial assertion that others should suffer as badly through apathy or ignorance” (Bottomley, 1992). The current state of sex education reflects all these divergent philosophies, and while the World Health Organisation (1984) stated that there should be a legal requirement for sex education in all schools it is not possible to meet this requirement until a consensus of agreement on what sex education is, or should be, can be agreed. If we decide that sex education should not only be directed towards making students aware of the risks of sexual involvement at an early age, but also lead to their avoidance of these risks then we should adopt effective strategies. An important distinction needs to be made between promoting abstinence and counteracting unwelcome pressures. Several programmes in North America have swung towards a highly conservative approach to sexuality. There are now schools involved entirely in the promotion of abstinence, including associated posters with a picture of a puppy and the caption “pet your dog, not your date” (Hafner, 1991). For many young teenagers initiation of coital activity is not a personal decision, but one that originates from external pressure and expectations (Cobliner, 1974; Kisker, 1985; Cullari, 1990), whether these are from a partner, friends, or emulating media proposed ideals. Sex education which addresses these pressures effectively should decrease the incidence of young teenage sexual intercourse by increasing the numbers of those who find themselves able to counteract unwelcome pressure. This is far removed from telling teenagers just to say “No”, which, predictably, is ineffective (Christopher, 1991). Health programmes using social learning theory have been criticised for simply postponing, for example, the onset of smoking rather than decreasing prevalence (Townsend, 1991). This would be a benefit rather than a detractor to sex education since life long abstinence is unlikely to be a desired aim! While young teenagers need to be aware that sexual intercourse is neither the “norm” nor expected of them, for those who are sexually active adequate contraceptive provision is required; this needs to be confidential, easily available and non judgmental. Teaching about contraception should concentrate on the practicalities and expectations of failure related to methods actually available to and suitable for use by teenagers. Increased effective contraceptive use can be achieved within a programme that is associated with overall decreased sexual activity (Howard, 1990). An individual’s sexuality depends on learning from the inter-relationship between biological, psychological, ethical and cultural factors (Greenberg, 1986). Appropriate sex education would enable students to learn the knowledge and skills needed to understand and negotiate sexuality in their lives (Welbourne-Moglia and Moglia, 1989). This should con-

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centrate on teaching method as much as content, including the application of social learning theory and the use of peers. Whether the methods of such studies can be translated into either long term or widespread sex education programmes remains to be determined. Imparting knowledge may have little effect in behavioural terms, but dangers to health cannot be avoided without knowledge and appreciation of risks (Maccoby et al., 1977). A core of factual information for inclusion in sex education is needed as well as those with medical expertise to provide continued accurate and current information for teachers. Currently within British schools “sex education” may be delivered, or have components, in Science, Religious Education, Physical Education, or have its own area in Personal Education. Not all factual information is necessarily best delivered through discrete sex education modules. Disease statistics, for example, can be covered in mathematics, in the same way that road traffic accident figures have been covered (Schools Maths Project, 1987). Allocation of time within the school day is highly competitive; sex education is often squeezed between subjects which have higher status afforded by examination requirements. Those teaching sex education often have little or no postgraduate training in the subject (Edet, 1991). The status of sex education and training for those teaching the subject need to be increased. Outside agencies are sometimes called upon to assist, but this may be devolved to the most convenient personnel, such as the school nurse or school medical officer. These outsiders may not have been trained to provide information about sexuality and it is almost certain that they will not have had training in educational process. Any overall plan for sex education needs to include evaluation. This is especially important given the potentially negative results from some health promotion programmes. The recent “Health of the Nation” (1992), a government statement, has provided certain goals which include long term assessment by determining, for example, the rates of teenage pregnancies, Survey reports can give interim evidence for changes in sexual lifestyles. If these changes include resisting unwanted sexual experience (Sex Education Forum, 1992) then the age at first intercourse may be an important statistic in determining the effectiveness of sex education. Teachers (and parents) are constantly being pressured to improve sex education (RCOG, 1991), criticised for doing too little, too late, for example, not clarifying eight year olds’ understanding of HIV/AIDS (Nash, 1992) or teaching out of context and failing to put explicit teaching of condom use to 15-16 year olds into a “moral framework” (Strickland, 1992). Unless those teaching sex education are provided with training, support and agreed guidelines on methodology, and procedures are evaluated, it would probably be more effective to install (free) condom machines in all

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school toilets and reserve the curriculum time for other subjects. Whatever the aims of sex education are to be, it is clear that more is not enough.

ACKNOWLEDGEMENTS

The authors’ data referred to in this article derives from a project in schools in the South West of England funded by the South Western Regional Health Authority.

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